Working Draft

ACCREDITATION REQUIREMENTS FORDENTAL RESIDENCY PROGRAMSEffective November 30, 2005

Updated November 2011

TABLE OF CONTENTS60.0PROGRAM INFORMATION

61.0PROGRAM DURATION

62.0INSTITUTIONAL RELATIONSHIPS

83.0PHYSICAL FACILITIES

104.0PROGRAM PROFESSIONAL STAFF

115.0PERSONNEL RESOURCES

116.0PROGRAM ADMISSION STANDARDS

127.0PROGRAM INSTRUCTION

178.0EVALUATION PROCEDURES

189.0MEDICAL AND DENTAL RECORDS

1910.0PATIENT CARE AND QUALITY IMPROVEMENT

2011.0LEARNING RESOURCES

2112.0RESIDENT ISSUES

2113.0RELATIONSHIPS WITH OTHER ORGANIZATIONS

ACCREDITATION REQUIREMENTSDENTAL RESIDENCY PROGRAMS

The Commission on Dental Accreditation of Canada

The Commission on Dental Accreditation of Canada (CDAC) is a partnership with membership from the public and organizations representing oral health care professionals, educators who prepare them and regulators responsible for their competence and continuing safe practice. CDAC, in consultation with its partners, develops and approves requirements for educational programs preparing dentists, dental specialists, dental interns/residents, dental hygienists and dental assistants. CDAC also develops and approves requirements or standards for institutional dental services. CDAC reviews educational programs and dental services by means of structured, on-site visits following receipt of submissions presenting detailed information in the required format. Programs and services meeting or exceeding the requirements are granted accredited status.

Vision

Quality educational programs and health facilities through accreditationMission

The CDAC evaluates oral health educational programs and health facilities to determine eligibility for and grant accreditation.

Basic Process

The starting point within accreditation is CDACs development, approval and ongoing revision of accreditation requirements. Educational programs and dental services are invited to apply for review against current requirements. Programs applying submit detailed documentation outlining evidence addressing the accreditation requirements. A survey visit is then arranged, and an accreditation survey team conducts interviews with faculty members, residents and other stakeholders to secure additional information. This process clarifies issues arising from the submission and generally verifies that the documentation reflects the program or service. The survey team submits a report to CDAC. CDAC then determines the eligibility of the program or service for accreditation.

Responsibilities of Accredited Programs or ServicesPrograms or services invite CDAC to conduct a review to assess eligibility for accreditation. Once initially accredited, CDAC notifies programs or services when reassessment is required in order to maintain accredited status.

Programs or services must submit reports to CDAC as requested following an accreditation survey. Programs or services must also, on their own initiative, inform the CDAC, in writing, of any significant changes, completed or pending, in supporting facilities, resources, faculty member complement, curriculum or structure.

CDAC requires the cooperation of programs in studies related to the improvement of the accreditation process. Educational programs are expected to cooperate in completing CDACs Annual Program Review.

Clarification of Terms

Particular attention should be paid to the wording of each requirement. For example, a requirement may take the form of either a must or a should statement. There is a significant difference between the two. Must statements reflect the importance of a particular requirement. The CDAC defines the terms as follows:

Must; Shall; CDAC expects:

These words or phrases indicate requirements that are essential or mandatory.

Should:This word implies that compliance with the requirement is highly desirable.

May or Could:These words imply freedom or liberty to follow a suggested alternative to the requirement.

Curriculum ApproachCompetency Based Education (CBE), Evidence Based Education (EBE) and Outcomes Based Education (OBE) are terms applied to educational programs, which build curriculum, resident learning experiences, and evaluation methods from documents that describe the knowledge, skills and values that a resident must possess to graduate.

Programs preparing health practitioners must also include consideration of the cognitive (foundation knowledge), the affective (values associated with professional responsibility) and psychomotor (preclinical and clinical). These abilities may be expressed through competencies or learning outcomes.

Respect for Educational Innovation and AutonomyCDAC strives to ensure that its accreditation requirements and processes do not constrain innovation or program autonomy. The expertise of educators in the development and implementation of educational programs, curriculum and learning experiences is fully acknowledged. For this reason, CDAC places its emphasis upon assessment of the programs ability to meet its stated objectives and outcomes. 0.0PROGRAM INFORMATION

0.1Provide the following information:

a. Name of Institution

b. Mailing and website addresses

c. Name and contact information for the site visit coordinator

d. Name of Dental Dean/Director along with telephone number

e. Name of Residency Director along with telephone number

f. Date program was establishedg. Maximum number of resident positions and the current enrollment

0.2List the Recommendations that resulted from the last accreditation survey report and describe how they have been addressed.

1.0PROGRAM DURATION

Requirement1.1The dental residency program must be a minimum of one (1) academic year in length.

Documentation Required

Identify the length of the program (in months).

2.0INSTITUTIONAL RELATIONSHIPS

Requirement2.1CDAC requires that the dental residency program must be sponsored by a faculty/school/college of dentistry. Health facilities providing the major component of program must have its dental service accredited by CDAC or the Order of Dentists of Quebec. The health facility must also be affiliated with the respective university by a formal affiliation agreement. If more than one health facility contributes to the education program, each institution must demonstrate a commitment to the program. Documentary evidence of agreements approved by the institutions must be available which identify respective responsibility including staffing, contribution of each institution, the period of assignment, and the financial commitments.

There must be provision for direct communication between the residency program and the health facility(ies) contributing to the education program regarding decisions that directly affect the residency program. Professional staff providing residency education must be involved in selection of candidates, program planning and ongoing program review and evaluation.

Documentation Required

a. Identify the faculty/college/school of dentistry that sponsors the dental residency program.

b. Attach as an appendix, an organizational chart of the program.

c. Attach as an appendix, the terms of reference for the decision making body that oversees the program.

d. Provide a list of the health facilities associated with the program and identify each facilitys commitment to the program and levels and areas of responsibility for the dental residency program.

e. Provide confirmation that a formal contract is in place between the program and the university.

f. Describe professional staff involvement in the selection of candidates, program planning and ongoing program review and evaluation.

Requirement

2.2The educational mission of the program must not be compromised by a reliance on residents to fulfil institutional service, teaching, or research obligations. Resources and time must be provided for the achievement of educational objectives.

Patient care must emphasize the patients overall oral health care needs. Documentation Required

a. Comment on the adequacy of resources to provide patient care and meet the programs educational objectives and confirm that residents are not required to fulfil institutional service, teaching, or research obligations.

b. Describe the budgetary basis that permits the program operations.

Requirement

2.3There must be opportunities for the programs professional staff to meet to review the activities of the program and to perform administrative, educational, and quality improvement functions. Minutes of these meetings must be recorded and maintained.

Documentation Required

Provide a list of the meeting dates from the past year, indicating whether a record of attendance was taken. Provide on site a copy of the minutes for the last two (2) years.

Requirement2.4A program director for the educational program must be identified and be responsible for all aspects of the program including experiences in affiliated institutions.

Documentation Requireda. Provide the job description and current curriculum vitae of the program director and indicate whether this individuals position is full-time or part-time.

b. Describe the program directors responsibilities for professional and administrative activities and indicate how these responsibilities are determined.

3.0PHYSICAL FACILITIES

Requirement3.1Dental residency education programs must be provided with adequate physical facilities and equipment within the health facility to assure delivery of optimal patient care in accordance with accepted standards of practice. The adequacy of facilities will be evaluated in relation to the available facilities and patient care services provided. Facilities and equipment must be assessed and upgraded periodically and maintained in good operating condition.

Each resident must have access to a well equipped operatory when providing direct patient care in a safe environment, equipped with the instruments, and supplies necessary for patient care procedures. Sufficient office and desk space must be provided to support administration of the program. Study areas and conference rooms must be available for residents use.

Documentation Required

a. Describe the dental clinic facilities available for the residents.b. Describe other health facilities available to the program.

c. Describe the programs plan for ongoing maintenance and replacement of clinical and laboratory equipment.

d. Describe residents study space.

e. Identify any areas in which there is insufficient space.

Requirement

3.2Policies and/or protocols must exist relating to Fire and Safety Procedures, Hazardous Materials and Waste Management, Infection Control, and Medical Emergency Procedures. Such policies and/or protocols must be consistent with related regulation, legislation and by-laws of the various jurisdictions; and must be readily available for the professional staff and support staff. Mechanisms must be in place to monitor compliance of these policies and protocols.

Documentation Requireda. Provide on site copies or web access to the policies and/or protocols outlined in 3.2. Describe how these policies and/or protocols are monitored.

b. Identify how often audits of infection control procedures are performed and recorded.

c. Describe the process in place to document the review of the expiry dates of emergency drugs and resuscitation equipment to assure its proper working order.

Requirement

3.3Protocols must be developed and implemented, in compliance with federal and/or provincial regulations and standards, for the use and monitoring of nitrous oxide, mercury, pharmaceutical and other substances and techniques that might be hazardous to patients and staff.

Documentation RequiredProvide on site copies or web access to the policies and/or protocols outlined in 3.3. Describe how these policies and/or protocols are monitored.

Requirement

3.4Written policies and procedures relating to quality assurance to ensure the safe use of ionizing radiation must be in place and be compliant with applicable regulations for radiation hygiene and protection. Mechanisms must be in place to monitor compliance of these policies and protocols by professional staff, support staff and residents. The design and construction of radiology facilities must provide adequate protection from ionizing radiation for the patient, operator and others in close proximity. The program must ensure that it is in compliance with provincial and federal regulations relating to radiation protection. Where provincial or federal regulations are not in force, the program must show evidence that radiography equipment is routinely inspected to ensure the safe use of ionizing radiation, and that the radiology facilities are designed in such a way to ensure that occupational and public exposure is not in excess of the current recommendations of the International Commission on Radiological Protection (ICRP).

In addition, the program must identify a radiation protection officer and have in place a quality assurance program that includes daily monitoring of radiographic quality.

Radiographs must be prescribed, based on the specific needs of the patient taking into account the existence of any current radiographs. Radiographs must be exposed solely for diagnostic purposes, not to achieve instructional objectives.

Documentation Requireda. Describe the facilities available for radiographic examinations.

b. Identify the radiation protection officer and provide a copy of the job description.

c. Provide on-site copy of the radiography quality assurance program.

d. Provide on-site reports of the radiation safety inspections undertaken since the last accreditation survey.

4.0PROGRAM PROFESSIONAL STAFF

Requirement

4.1The residency program must be adequately staffed by generalist and specialist dentists with competence in all areas of dentistry taught in the program. The professional staff complement will be assessed by the extent to which they are able to implement program objectives and supervise residents.

Professional staff directly involved in the teaching program, including consultants, must be qualified by education, licensure/registration, dental residency experience and current clinical competence in the subject matter for which they are responsible.

The number and distribution of professional staff must be sufficient to provide patient care within the facility. There must be mechanisms for the appointment, review and reappointment of professional staff.

Documentation Required

Provide the following information for each dental professional staff member:a. Current curriculum vitae for each dental professional staff member.b. Medical staff status and type of privileges granted.c. Date of appointment.d. Hours per week in the program supervising residents and/or consulting in the clinic.

Requirement

4.2 Professional staff involved in the program must:a. Be fully aware of the philosophy and objectives of the program.b. Take an active role in the presentation of seminars, lectures, conferences, journal clubs, and other didactic activities.c. Provide feedback and evaluations to the residents.d. Discuss with residents patient evaluation, treatment planning, patient management, and complications and outcomes of all cases.

Documentation Required

Identify how professional staff members:a. Are aware of the objectives of the program.b. Take an active role in the presentation of seminars, lectures, conferences, journal clubs, and other didactic activities.c. Supervise and evaluate residents.d. Discuss with residents patient evaluation, treatment planning, patient management, and complications and outcomes of cases.

5.0PERSONNEL RESOURCES

Requirement5.1The program must ensure that personnel policies and practices supporting patient care and patient safety are established and maintained.

The number and distribution of clerical and support staff must be sufficient to ensure that patient care and administrative functions are carried out in an effective manner. Sufficient allied dental personnel must be available to assist residents when they are providing direct patient care procedures. There must be sufficient allied dental personnel to enable residents to develop competence in four-handed dentistry techniques.

Residents must not regularly perform the tasks of dental assistants, laboratory technicians or clerical personnel.

Dental hygienists, dental assistants, laboratory and prosthetic technicians, and nurses assigned to the program must be available to meet the needs of patients.

Written administrative and patient care policies must be developed to guide the allied staff in accordance with program policy.

Documentation Requireda. Provide a list of full- and part-time allied and clerical personnel in the dental service/department under the following disciplines:1. Dental Hygienists

2. Dental Assistants

3. Dental Laboratory Technicians

4. Registered Nurses

5. Clerical Staff

6. Other (specify)b. Describe how the staffing pattern provides sufficient allied dental personnel to enable residents to develop competence in the four-handed dentistry techniques.

c. Provide a copy of the health facilitys policy and procedure manual on site during the survey visit.

6.0PROGRAM ADMISSION STANDARDS

Requirement6.1Dentists with the following qualifications are eligible to enter dental residency programs accredited by CDAC.a. Graduates from institutions accredited by CDAC and/or the Commission on Dental Accreditation of the American Dental Association (CODA/ADA).b. Graduates of foreign dental schools that possess equivalent educational background and standing.

There should be an admission policy that is designed to identify those residents with standards of integrity, motivation, industry, resourcefulness, and basic knowledge required for completing the hospital dental residency education program. Non-discriminatory policies must be followed in the selection process.

Documentation Requireda. Attach as an appendix, a copy of the admission policy for the dental residency education program.

b. Briefly describe the admission process.

7.0PROGRAM INSTRUCTION

Requirement

7.1The residency program must clearly define its educational objectives and/or outcomes and be structured in a fashion that permits residents to achieve these objectives and/or outcomes. These educational objectives and/or outcomes must be made available to individuals applying to the program.

Clinical experiences must be supplemented by related and relevant formal educational activities. These activities must include planned teaching sessions that are regularly scheduled. While such activities may be informal in presentation, they must be formal and structured in organization.

Residents assignments to services outside the department of dentistry must be relevant to the residency program and related objectives are required for each assignment.

The program must provide residents with a formal orientation at the beginning of the program that includes: a. Role and responsibilities of residents.b. Rotations within the program and their relevance to the educational program.c. Procedures for emergency call.d. Confidentiality of patient information.e. Adverse outcomes.f. Evaluation methods.Residents should develop sufficient understanding of the various aspects of the organization and function of the health facility.

An appropriate balance of faculty member involvement between teaching and research must exist so that the quality of the education program is not compromised. Residents must be given assignments that require critical review of significant literature.

If the program provides off-site rotations/experiences for the residents, the objectives for these rotations/experiences must be defined.

Documentation Required

a. Provide a brief overview of the education program with respect to the programs educational objectives and/or outcomes and provide a copy of the orientation information provided to residents. Append a copy of the code of resident behaviour.

b. Describe the orientation process for new residents.

c. Attach as an appendix a schedule of the departmental seminars and/or lectures, which will be conducted for the resident(s) for the current program year. Indicate the titles or topics for each seminar and/or lecture to be presented.

d. Describe the variety of educational seminars and clinical activities provided within the program.

e. Identify the percentage of time dental residents spend in each of the following areas:1. Outpatient department2. Operating room3. Inpatient care4. Assignment to other services5. Conferences/seminars6. Other (please specify)f. Describe opportunities for residents to review the literature (i.e. journal clubs, self-directed learning).

g. List investigative projects, research activities carried out by residents and any articles, presentations and publications, which have originated from the program since the last accreditation survey. h. Describe the off-site rotations/experiences provided to the residents including their objectives, duration, and the patient experiences scheduled.

Requirement

Clinical Program - Inpatients7.2Residents must receive training and experience in the comprehensive management of individual hospitalized patients or same-day surgery patients from admission to discharge. This must include the following:a. Admitting and discharging patients.b. Obtaining medical histories and appropriate physical examinations.

c. Obtaining informed consent.d. Prescribing treatment and medication.

e. Providing dental care in the operating room.

f. Preparing the patient record, including notation of pre and postoperative orders, progress notes, description of surgical procedures and discharge summaries.

Residents must make rounds on dental inpatients as required.

Documentation Required a. Identify the number of admissions in which the residents are involved.

b. List the types of procedures performed or assisted by the resident(s) and the number of patients for whom each procedure was provided in the operating room for the most recent 12-month period.

c. Comment on the availability of operating room periods to meet the educational needs of the program.

d. Identify residents responsibility for i) performing the following activities, and ii) entering the information for the activities onto the hospital charts:1. History2. Physical examination3. Pre and postoperative orders4. Progress notes5. Description of surgical procedures6. Discharge summarye. Identify how frequently residents make rounds for dental inpatients, and other hospitalized patients (indicate from which services).

f. Identify the number of inpatient consultations provided and what there origin, if available.

Requirement

Clinical Program - Outpatients7.3Ambulatory care experience should be sufficiently varied and complex to provide opportunity for residents to increase their diagnostic ability, skills and judgement in clinical dentistry. The program may elect to emphasize certain disciplines of dental practice depending on available resources. Residents must be aware of the procedures for requesting and reviewing consultations for patients.

Documentation Required

a. Indicate the number of half-days per week residents are scheduled in the dental clinic for each year of the program. b. Describe the criteria used to determine how patients are accepted for limited or comprehensive dental care.

c. Describe how patients are assigned to residents and comment on the availability of patients.

d. Describe how residents responsibility to the patient and supervising faculty member is assigned and monitored.

e. Identify what proportion of patients assigned to residents for dental treatment have their treatment completed within the facility. Describe the recall program.

f. Describe the variety of outpatient procedures performed by residents during the most recent 12-month period.

g. Identify the number of outpatient consultations provided and origin, (if available).

h. Describe strategies to overcome any problems caused by a shortage of patients.

i. Describe how fees are collected for services and if residents are responsible to collect fees.

The following list, although not exhaustive, represents the content areas that CDAC expects to find in the program. These content areas may be present with varying degrees of emphasis and may not necessarily be identified by specific course title, name or seminar.

Medical Risk Assessment

7.4The program must provide formal instruction and clinical experience in medical risk assessment. The term medical risk assessment refers to obtaining a patients medical history, and arranging for and interpreting the laboratory, radiographic and other data as needed to plan and carry out dental therapy and management of hospitalized and ambulatory patients.

The overall goals of training in medical risk assessment are to develop the ability to:a. Recognize significant deviations from normal health status, which may affect dental management.

b. Make informed judgements on the risk of dental procedures to both hospitalized and ambulatory patients.

c. Identify the need for medical consultation.

When providing dental care for patients, residents must, during the initial visit, obtain and document a medical history, perform a regional examination of the head and neck, perform an appropriate physical examination, assess blood pressure and pulse, and arrive at a medical risk assessment prior to initiating dental care. These procedures should be repeated as needed.

Documentation Required

a. Describe the nature and extent of the training related to physical diagnosis, medical history taking, and interpretation of laboratory data.

b. Identify the staff, including their qualifications, responsible for this training.

Requirement

Clinical Program - Emergency Training

7.5Residents must receive training and experience in dental and medical emergency procedures that will enable them to anticipate, diagnose and treat emergencies that may occur concurrently with dental procedures.

This should include the following:a. Review of the medical history to recognize factors which may predispose a patient to a systemic emergency during dental treatment.

b. Anticipate systemic emergencies by preoperative evaluation and management.

c. Diagnose the primary systemic abnormalities in a patient with a medical emergency.

d. Support a patients respiration and/or circulation when required because of systemic collapse.

e. Evaluate and manage seizure and sudden loss of consciousness in a patient.

f. Treat allergic reactions encountered in the course of dental treatment.

All residents must have current certification in basic life support (CPR).

Residents should be called to the emergency service for dental and maxillofacial problems. They also should treat dental emergencies in the dental clinic and on inpatient services.

Documentation Required

a. Describe how residents receive training in managing dental emergencies. Provide a copy of the emergency call schedule.

b. Indicate how frequently residents are called to the emergency department for the management of trauma and acute dental conditions. Append residents on-call schedule.

c. Describe the level of supervision provided to residents while they treat dental emergencies.

d. Describe how the outcomes of emergency procedures are assessed.

e. If residents are subjected to simulated medical emergencies, describe the nature and outcome of such simulation.

f. Identify how residents certification in basic life support (CPR) is monitored.

Requirement

Anesthesia and Pain Control

7.6The residency program must provide formal instruction and clinical experience in anesthesia and pain control. Program objectives must stipulate the intended outcomes of training in pain and anxiety control.

The program may include an anesthesia rotation. The anesthesia rotation must be structured to provide residents with knowledge and experience in the management of patients undergoing general anesthesia. The anesthesia rotation must include experience in the following:a. Preoperative evaluation.b. Assessment of the effects of pharmacologic agents.c. Venipuncture technique and administration of intravenous agents.d. Patient monitoring.e. Airway management.f. Assessment of patient recovery from anesthesia.

Residents must receive advanced instruction and clinical experience in the control of pain and anxiety in the conscious patient through the use of behavioural management, local anesthesia and other pertinent techniques.Documentation Requireda. If an anesthesia rotation exists, describe:1. The goals and objectives of the rotation.2. Its duration.3. The qualifications of the anaesthetist supervising the rotation.b. If I.V. sedation facilities exist or are available to residents, describe:1. Guidelines for use of I.V. sedation.2. Levels of sedation administered.3. Nature of resident training in I.V. sedation.4. Qualifications of staff person(s) responsible for on-site supervision for I.V. sedation.5. Range of treatment provided via I.V. sedation.6. Number of cases treated by I.V. sedation in most recent calendar year.c. If nitrous oxide sedation facilities exist or are available to residents, describe:1. Guidelines for use.2. Levels of sedation administered.3. Nature of resident training.4. Qualifications of staff person(s) responsible for on-site supervision for nitrous oxide sedation.5. Range of treatment provided via nitrous oxide sedation.d. Describe the nature and duration of the advanced instruction provided to the residents in behavioural management, local anesthesia, and analgesia.

e. Identify the staff, including their qualifications, responsible for this instruction.

8.0EVALUATION PROCEDURES

Requirement8.1Formal evaluation of residents, teaching staff and the education program, including program outcomes, must be documented to determine the extent to which program objectives are being met. Resident EvaluationAn effective and valid system of resident evaluation must exist and must be applied. Understandably these systems and techniques will vary from program to program. However, CDAC must be satisfied that these systems accurately establish the basis for judgments, which determines the residents successful completion of the program.

Residents must receive written evaluations at the midpoint and the conclusion of the program. Evaluations must be discussed with, and acknowledged by, the residents.

Documentation of the residents activities, their formal evaluations during all rotations and evaluation meetings with residents, must be kept in a permanent file.

Residents must be evaluated on the accuracy and completeness of their record keeping. The patient record system must include together with appropriate dates, signature and authorizations, medical and dental histories, informed consent, results of examinations, diagnostic aids, record of radiographic procedures, consultations, diagnosis/problem list, integrated and comprehensive treatment planning (including estimated fee), details of treatment rendered, cost, completion, review and follow-up procedures.

Professional Staff EvaluationProfessional staff members should receive feedback with respect to their teaching and supervisory responsibilities.

Documentation Requireda. Briefly describe how the program formally evaluates residents performance including their achievement of program objectives and program outcomes.

b. Identify how evaluation feedback is provided to residents at the midpoint and the conclusion of the program.

c. Provide a copy of the resident evaluation form. Provide copies on site of formal evaluations of residents.

d. Describe how the program evaluates residents on the accuracy and completeness of their record keeping.

e. Describe how residents provide feedback to the professional staff in response to their teaching and supervisory responsibilities and provide a copy of professional staff evaluation form.9.0MEDICAL AND DENTAL RECORDS

Requirement

9.1Complete, accurate and legible records must be maintained for each registered dental patient. An accurate medical record must be maintained for every patient receiving inpatient, outpatient or emergency care. The medical records must be accurately documented and readily accessible. Patient care records must include the following documentation and must be signed and dated:a. Current medical history.b. Description of appropriate physical examination.c. Chief complaint.d. Risk assessment.e. Recording radiographic interpretation.f. Dental diagnosis.g. Proposed dental treatment plan and informed consent for treatment.

Documentation Requireda. Provide written confirmation from the Health Records Department that the standards for medical record services, as noted by the facility and Accreditation Canada or Provincial statute are adhered to by the dentist members of the medical staff.b. Provide confirmation that patient authorization for his/her chart to be reviewed as part of the accreditation process has been obtained.

c. Provide on site 10 patient charts selected by the program for review by the survey team members. Patient care records must include the following documentation and must be signed and dated:1. Current medical history.2. Description of appropriate physical examination.3. Chief complaint.4. Risk assessment.5. Recording radiographic interpretation.6. Dental diagnosis.7. Proposed dental treatment plan and informed consent for treatment.10.0PATIENT CARE AND QUALITY IMPROVEMENTRequirement

10.1Policies and/or protocols must exist relating to the following:a. Audit of Patient Careb. Confidentiality of Patient Informationc. Consultative Protocolsd. Informed Consent e. Patient Continuing and Recall Care

f. Patient Records

g. Professional Conduct in an Educational EnvironmentSuch policies and protocols must be written and readily available for the professional staff and support staff. Mechanisms must be in place to monitor compliance of these policies and protocols.

Documentation RequiredProvide on site copies or web access to the policies and/or protocols outlined in 10.1. Describe how these policies and/or protocols are monitored.

Requirement

10.2The program must have a documented quality improvement process in place that demonstrates dental professional staff and residents review and evaluate the pattern and quality of patient care provided, including the review of patient care outcomes.Documentation RequiredProvide a copy of the quality improvement process and meeting minutes to confirm dental professional staff and residents review and evaluate the pattern and quality of patient care, including the review of patient care outcomes.

Requirement

10.3Patients and/or patient care advocates should be surveyed regarding their impressions of the care provided and this feedback should be used to evaluate and enhance the clinical program.

Documentation Required

a. Describe how patients and/or patient care advocates are surveyed regarding their impression of the care provided.

b. Describe how this feedback is used to improve the clinical program.

11.0LEARNING RESOURCES

Requirement11.1Access to library services appropriate for the professional needs of the program must be provided.

Documentation Required

Describe the library services and how professional staff and residents access library services.

Requirement

11.2Professional staff and residents must have access to computers for electronic access of information.Documentation Required

Describe how the program provides electronic access to information.12.0RESIDENT ISSUES

Requirement12.1Residents must be provided with written information that includes:a. Tuition, stipend or other compensation.b. Vacation and sick leave.c. Practice privileges and other activities outside the education program.d. Grievance procedures.e. Professional liability coverage.f. Due process policy.g. Current accreditation status of the program.

There must be an institutional due process policy that provides for due process for all individuals who may be potentially involved when actions are contemplated or initiated which could result in dismissal of a resident.

Residents should be encouraged to participate in their provincial and national professional organizations.

Documentation Requireda. Attach as an appendix, the information provided to residents regarding the program.

b. Attach as an appendix, the programs grievance policy.

c. Describe how residents membership and participation in provincial and national professional organizations is encouraged.

13.0RELATIONSHIPS WITH OTHER ORGANIZATIONS

Requirement13.1Activities that are mutually beneficial to the residency education program, related health facilities and the undergraduate program in dentistry are encouraged. If appropriate, mutually beneficial activities between and among graduate/postgraduate programs should be encouraged.

Cooperating with health departments and community service programs should be sought to provide residents with an orientation to delivery of health care in the community, especially for groups with special needs such as geriatric, disabled and medically-compromised patients.

Documentation Required

a. Describe how residents are introduced to those aspects of practice that interface with other health professionals.

b. Describe the functional relationships with the following:1. Other health care facilities.2. Community health groups, service agencies, local and provincial health departments, and community service programs with a dental component.